503.1E1 Student Records Request Form for Parents or Students

The undersigned hereby requests permission to examine and/or receive copies of the Spirit Lake Community School District's official student records of:

____________________________________                       _____________________________

(Legal Name of Student)                                                       (Date of Birth)

The undersigned requests to examine and/or receive copies of the following official student records of the above student:

______________________________________________________________________________

______________________________________________________________________________

The undersigned certifies that they are the parent and/or legal guardian or of the above student or that they are the above student.

The undersigned (check one):

( ) does want copies of the above-stated student records. I understand that the District may

     charge me a reasonable fee for copies.

 ( ) does not want copies of the above-stated student records.

                                                                                   

___________________________________

(Signature)

                                                                       

___________________________________

(Printed Name)

 

APPROVED:

Date:

 

Address:

Signature:

City:

Title:

State:                                  Zip:

 

Phone Number:

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Approved:

Reviewed: 5/13/13; 6/10/19

Revised: